Board of Nursing Practice Proposals Still a Concern

At the August 5 meeting of the Minnesota Board of Nursing, the Board's Nursing Practice Committee submitted its formal recommendation regarding the LPN scope of practice issue. 

• Read the recommendation in its entirety  8-5-10 Nursing Practice Committee Report and Recommendation.pdf
• Read MNA's formal notification of our position sent to the Board on Aug. 4  Letter to MN Board of Nursing 8-4-10.pdf

Additional History

The Minnesota Board of Nursing’s Nursing Practice Committee met Monday July 19th to continue discussions related to redefining LPN scope of practice. The board’s practice committee has been working on this issue for many years. In 2002, LPN educators requested the MBON, and a now defunct Robert Wood Johnson funded group (labeled MN Colleagues in Caring), “to address the perceived differences between practical nursing practice and the scope of practice specified by regulation” (MBON Draft 3, Implementation of Recommendations, 7/2010). An LPN practice committee was formed by the MBON.

MNA was allowed two members and one staff as representatives on this committee. If they had to be absent, no substitutes were permitted. In the end there was little agreement and several recommendations were made to the board of nursing.

1. The nature of observation and assessment in practical nursing practice needs to be clarified and differentiated from observation and assessment in professional nursing practice.
2. The nature of delegation and supervision in practical nursing practice needs to be clarified and differentiated from observation and assessment in professional nursing practice.
3. Ongoing education of those in supervisory positions is needed, with clear examples of how to communicate the role differentiation of practical nursing practice and professional nursing.

MNA has made it very clear that differentiating and clarifying practice would not include expanding LPN scope of practice to include assessment, delegation, and supervision. Rather, supervisors, LPNs, and RNs should be better educated about the Grounds for Discipline including practicing beyond one’s legal scope of practice; and that the MBON should pursue discipline of persons both performing outside their scope, and those allowing it.

The board of nursing then gave these charges to the Nursing Practice Committee:

• Analyze the recommendations of the LPN scope of practice work
• Determine a plan to implement the recommendations  of the LPN scope of practice work

The Practice Committee presented it 3rd Draft of Implementation of Recommendations of the MN Colleagues in Caring LPN Practice Committee (which MNA has been objecting to). There is a great deal of editing left to do, including narratives for the models, but the nursing board committee members plan to submit the report to the August 5th MBON meeting for approval. Many changes have been made but the fundamental concerns of expansion of LPN practice, the use of committee rather than the legislative process for law changes, and the continuing lack of clarity between LPN and RN roles, remain.  Early next week, MNA will send a formal response to the Board's Practice Committee outlining these concerns.  However, MNA members should be prepared for an outcome that does not reflect our concerns.

Why is the Minnesota Nurses Association pursuing this action plan with the Board of Nursing at this time?

1. MNA is seriously concerned that if this document is passed by the Board of Nursing as written, it will result in legitimizing the current illegal practice by employers of interchanging RNs and LPNs, jeopardizing the safety of patients in MN health care settings. The lack of communication by the Board regarding the content and time frame of implementation of this process has been vague and uncertain.
2. MNA believes that these proposed changes, which re-interpret the definitions of the Nurse Practice Act and have significant ramifications for the safety of the public, should be required to be subjected to a formal public policy process.
3. MNA does not believe that the Board of Nursing has addressed the clarity promised in the model for the change in practice of LPNs in the areas of assessment, supervision, and delegation.
4. MNA’s Commission on Nursing Practice has repeatedly offered to meet and dialogue about the objections to this proposal with the intent of drafting language that may be more acceptable. To date, the Board has not agreed to meet.

What is nursing assessment?
The Board has not defined assessment or how it is using the term in the models of practice they have outlined. The term used by the Board is inconsistent with the historical, and current professional and legal interpretation and utilization of the term. It is a universal truth that most people have the ability to assess. However, the difference is that assessment needs to be within the context of nursing and safe patient care as well as the professional and technical differences in its application based on legal and professional definitions and the education and licensure level required.

Assessment – Definition: A systematic, dynamic process by which the registered nurse, through interaction with the patient, family, groups, communities, populations, and other healthcare providers, collects and analyzes data to then evaluate and progress the plan of care. Assessment may include the following dimensions: physical, psychological, socio-cultural, spiritual, cognitive, functional abilities, development, economic, and lifestyle. (Scope and Standards of Practice, 2004, ANA)

What is the difference in levels of assessment?

1. The LPN participates in assessment with the RN by collecting data, recognizing alterations in the client’s condition and reporting to the RN. The LPN also participates in the plan of care and evaluating the response to interventions. Assessment is not an independent process for the LPN.
2. The RN is educated to interpret and analyze data, attach nursing significance to the observations, develop a care plan by setting priorities, identify outcomes, write nursing actions, coordinate the different dimensions of the care plan, and evaluate the care for effectiveness and appropriateness. Both LPNs and RNs provide for the maintenance of safe and effective nursing care.

All health care workers as part of a team do some level of observation dependent upon their level of preparation/education. Only health care personnel educated at the professional level (i.e. physical therapy, occupational therapy, social worker) perform complete assessment, which means interpreting the findings with the purpose of developing a plan for intervention. Technically trained health care workers can perform some of the tasks involved in the assessment process (e.g. collecting data and reporting to the appropriate professional health care person).

Example of Pain Management
Any member of the health care team could report a patient’s pain to an RN, who would assess the need to change the pain medication by following up with the patient and considering all the information available. Nursing assistants, licensed practical nurses, or other disciplines such respiratory or physical therapists can provide this information. For example if the pain is abdominal, it may be from a variety of possible sources – bladder infection, bowel blockage, etc. The RN is educated to take all of these possibilities into account before making a decision to pursue a change in pain medication or implement other pain-relieving interventions. The LPN is licensed to be able to give the pain medications or implement pain-relieving interventions as assessed and directed by the RN.

Doesn’t MNA want APRNs to practice within the full scope of their practice? Why not allow LPNs to do the same?
APRNs are legally authorized to practice at this advanced level by the required level of education and a required specialty certification process. However, APRNs experience barriers to practice by external requirements of needing a collaborative management agreement with a physician. What the Board of Nursing is proposing for the expansion of the Licensed Practical Nurse scope is not currently contained within the legal definitions of the Nurse Practice Act or supported through additional education.

Call or e-mail the MNA Nursing Practice department with any further questions:

Carol Diemert, RN, MSN
Nursing Practice Specialist
1-800-536-4662, ext. 149, (651) 414-2862

Cindy Schoenecker, RN, MA
Nursing Practice Specialist
1-800-536-4662, ext. 126, (651) 414-2826

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